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Professional Education
Loss Lessons: Recognition of Wernicke Encephalopathy
Wernicke encephalopathy (WE) is a syndrome commonly seen in patients with alcohol use disorder who do not take adequate thiamine. WE should be suspected in any patient with conditions that may lead to malnutrition in combination with any of the following symptoms: altered mental status ophthalmoplegia, ataxia, delirium, and hypotension. Considered a medical emergency, it must be reversed to prevent permanent deficits. This case illustrates a cascade of errors which led to permanent disability. Some practical interventions to quickly recognize and reverse the condition are offered following the case presentation, which will be helpful for gastroenterology/gastroenterologists, ophthalmology/ophthalmologists, and neurology/neurologists.

May 11, 2023, Inside Medical Liability Online
Postpartum Malpractice Claims: Can We Understand Preventable Harms and Socioeconomic Factors?
Rates for maternal morbidity and mortality are higher in the U.S. than in any other developed country—and many of the harms suffered by patients are preventable. In a multifactorial study, David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Jacqueline Ross, PhD, RN, CPAN, Coding Director, Department of Patient Safety and Risk Management, The Doctors Company, and Shelise Valentine, RNC, MSN, Director of Clinical Education, Healthcare Risk Advisors, part of TDC Group, investigated postpartum claims to develop clinical recommendations to decrease the risks of postpartum morbidity and mortality.

Professional Education
Burnout: Spotlight on Improving Practice Efficiencies
In this CME program, Christine Sinsky, MD, highlights practice redesign strategies to help clinicians improve practice efficiencies, recover professional fulfillment, and improve patient safety.

Professional Education
Loss Lessons: Practicing Out of Bounds
Unlicensed staff are vital to efficient patient flow in medical practice. Healthcare organizations have many tasks that are safely and effectively carried out by skilled unlicensed support staff every day. To reach such efficiencies with safety and reliability, careful attention must be given to scope of practice and state and local statutes regarding delegation and supervision. Policies and protocols that outline the scope of practice for unlicensed staff to follow independently, and when they must consult with licensed staff, help even the most talented of your staff understand their boundaries. This case illustrates how informal verbal guidelines can blur the lines and cause well-meaning staff to cross the boundary lines of their scope leading to misdiagnosis and death.

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